Smoke Barrier Wall Penetrations Compromise Fire Resistance
Penalty
Summary
Surveyors observed that the facility failed to ensure smoke barriers were constructed to a minimum 1/2-hour fire resistance rating as required by code. Specifically, on April 29, 2025, wire bundle penetrations were found within the smoke barrier walls above the ceiling at the cross corridor doors in both the A wing and B wing. These penetrations were located within the electrical conduit and were confirmed by maintenance staff at the time of observation. The deficiency was identified as potentially affecting 17 occupants within the adjacent smoke compartment if smoke were to pass through these penetrations during a fire. No information regarding the medical history or condition of specific residents was provided in the report.
Plan Of Correction
On April 29th, 2025, the smoke compartments/smoke barriers on unit A and B were immediately repaired by the maintenance department. Maintenance personnel performed a thorough compliance check of all smoke barrier panels throughout the facility. The Maintenance Director has added monthly barrier penetration checks to the Maintenance Care work-order program. Reminders will be auto-generated by the program and documented through Maintenance Care upon completion. The Maintenance Personnel conducted a thorough compliance check of all smoke barrier penetrations throughout the facility to ensure safety and adherence to fire codes. Following this evaluation, the Maintenance Director has implemented a new procedure that incorporates monthly smoke barrier penetration checks into the Maintenance Care work-order program. This proactive approach involves regularly monitoring and assessing the integrity of smoke barriers, which are crucial for maintaining fire safety. As part of this initiative, reminders for these checks will be automatically generated by the Maintenance Care program. Each check completion will be documented within the system to maintain a comprehensive record of compliance and any necessary maintenance actions taken. Maintenance Personnel will conduct a weekly audit for 4 weeks, then monthly or until the home has reached substantial compliance. Results will be taken to QAPI. The Maintenance Director or designee is responsible for sustained compliance. Date of Compliance: June 16th, 2025